Noma: A Neglected Tropical Disease of Public Health Importance

Dear Editor, In the 17th meeting of the Strategic and Technical Advisory Group for Neglected Tropical Diseases (NTD) organized in December 2023, the World Health Organization (WHO) has added “Noma” as the 21st disease in the list of NTDs.[1] Noma, also known as “cancrum oris,” is an opportunistic gangrenous infection affecting the face and mouth, affecting the marginalized population. This disease is of a noncommunicable nature and most commonly occurs in children aged between 2 and 6 years or is associated with either malnutrition, immunocompromised state, or poor oral hygiene.[2,3] Noma disease develops in the 1st two weeks of as an acute necrotizing gingivitis and edema of the face and mouth. Patients who are diagnosed timely and receive appropriate treatment show a mortality rate from 0% to 38%. For those patients who remain undiagnosed and left untreated, the disease advances to a necrotizing lesion and leads to high mortality (>90%). In the next phase, survivors show wound healing and scarring, resulting in facial and joint deformities. Approximately 1 year later, the survivors show significant loss in visual and physical deformities, resulting in difficult food consumption.[4] The current burden of the disease is unknown and uncertain as it is associated with high stigma, rapid progression, and high case-fatality rate. The most cited data are of 1998 which was estimated by WHO through the Delphi technique, reporting an incidence of 140,000 cases per year and 770,000 cases of sequalae.[4] A symposium was organized in Switzerland on September 20, 2024 on the theme “Defining the Noma Research.” The key themes of discussion in this symposium were: surveillance and prevention of noma; physical and mental well-being of persons affected by noma; noma stages and reconstructive surgery; and microbiological and therapeutic aspects of noma.[4] The symposium identified the following topics as most pressing. First, there is still no accurate epidemiological research that establishes the incidence, prevalence, and geographic distribution of the disease. Second, standardized clinical definitions and practical diagnostic criteria are needed for early case detection so that community health workers and primary care providers can spot acute necrotizing gingivitis (the first stage of noma) before it becomes gangrenous and irreversible. Third, microbiological studies need to explain how oral dysbiosis works and find treatment targets. When it comes to antimicrobial resistance, there needs to be evidence-based antibiotic protocols with set doses and times. Fourth, research on risk factors that look at genetic susceptibility, immunological signatures, and specific social determinants (not just poverty descriptors) can help create targeted prevention strategies that are part of child health, nutrition, and WASH programs. Fifth, the survivors’ agenda calls for health systems research on the effectiveness of reconstructive surgery, psychosocial rehabilitation, and support for reintegration.[4,5] We can go from just recognizing a disease to getting rid of it by improving surveillance, doing research that focuses on the person, and getting survivors involved in a meaningful way. Now is the time to act, while the world is still paying attention and before another generation of children suffers needlessly from this condition that can be easily avoided. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.